A Conversation with Secretaries of Health and Human Services

(L-R) Donna E. Shalala, Former U.S. Secretary of Health and Human Services and Former President, University of Miami; and Kathleen Sebelius, Former U.S. Secretary of Health and Human Services

(L-R) Donna E. Shalala, Former U.S. Secretary of Health and Human Services and Former President, University of Miami; and Kathleen Sebelius, Former U.S. Secretary of Health and Human Services

Repealing the Affordable Care Act (ACA) may be easy, but replacing “Obamacare” will be a difficult challenge for Congress and the Trump administration, according to Donna E. Shalala, former U.S. Secretary of Health and Human Services (HHS) and former president, University of Miami. “Presidents lose power every day in office, so you have to do major reforms right at the beginning.”

Kathleen Sebelius, former U.S. Secretary of Health and Human Services, joined Shalala in offering their insights in the closing keynote session, "A Conversation with Secretaries of Health and Human Services."

Tracing the history of health care reform in the past century, Shalala said that taking giant steps requires certain elements, including a president who is passionate about reform, and is willing to use a great deal of political capital to get it passed.

For instance, Franklin Roosevelt was successful in gaining approval for Social Security in the early 1930s, but was unable to win over the American Medical Association (AMA) on providing health coverage to the elderly. That didn’t happen until President Lyndon Johnson was able to push through the Medicare and Medicaid programs in 1965.

Looking at the Republican-led repeal effort, Shalala said that mixing coverage and cost issues is a recipe for failure. “President Johnson put more money in the budget when launching Medicaid and Medicare, as did President Obama with the ACA,” she said. “In terms of politics, that’s very different than pulling money out of the system.”

To be successful, presidents also have to “hush” the economists who say the nation can’t pay for more health care, she said. “Presidents also have to stay out of the weeds, she added. “Bill Clinton loved health care and could discuss all the nuances. On the other hand, Johnson just wanted a bill that would cover the elderly, while Wilbur Mills [chairman of the House Ways and Means Committee in the 1960s] wanted to cover the poor. That’s why we have Medicare and Medicaid.”

Finally, Shalala said presidents have to “explain and explain” why health care reform is needed. Otherwise, they lose control over the debate. “You really need to have all these elements in place in order to take a giant step, which is why there are so few instances of major change in American history.”

An inside perspective on Obamacare

Sebelius, who oversaw the implementation of the ACA, reflected on Obama’s passion for increasing health coverage for millions of uninsured American. “He had seen his mother die at a young age, while fighting with insurers about benefits,” she said. “Health care reform became a personal issue for him, even though the economists said ‘don’t do it.’ In terms of coverage, the ACA worked and 20 million more people now have coverage.”

The ACA has also been successful in changing the health care delivery model toward value and outcomes, rather than fee for service, Sebelius added. “That was a big part of the reform, and that change is likely to continue.”

Sebelius said a fundamental issue in “repeal and replace” is where would costs be lower, and where would they be higher. “Capping the cost to the federal government, would just shift those costs to the states, employer and individuals. Unless we can find a way to bring down the costs for everyone, we’re just shifting things around.”

As for cost-cutting alternatives, Sebelius said offering Americans lower-cost high-deductible insurance plans would result in people delaying visits to their doctors until they wind up in more expensive hospital emergency rooms. “Health savings accounts have also been proposed,” she added. “They are fine if you can afford the underlying coverage, but they won’t help if you have a baby in a neonatal intensive care unit or an adult who needs chemotherapy.”

Sebelius said she hopes the GOP-controlled Congress can come up with a plan to provide better insurance with lower costs. But shifting Medicaid funds to the states through block grants in order to reduce the federal budget would be likely to cut reimbursements for physicians and other providers, she added.

“Americans do share similar values about health care, including providing extra support for children and the most vulnerable people,” she concluded. “I hope any reform proposal reflects those values.”